Lakshmi Durga Chava Director ( Community Managed Health and Nutrition) Society for Elimination of Rural Poverty Dept. of Rural Development Andhra Pradesh 16.04.12 Outline of the presentation

• Background • Innovation • Processes W Phase1 : Platform establishment to demand entitlements W Phase 2: Focus to bring behaviour change at household level W Phase 3: Community based monitoring and evaluation • Impacts • Challenges • Scale up plan • Conclusion

2 Society for Elimination of Rural Poverty (SERP) W Z Autonomous Society established by Govt of Andhra Pradesh in 2000. Z Responsible for implementation of AP Poverty reduction project supported by WB & the state Govt. Z Works with network of Self Help Groups (SHGs) and their federations with women. Z Works in close coordination with mainstreaming departments

3 Holistic Development of rural ¾ S.E.R.P poor ¾ Women’s Additional Income of Rs.60000 / of Additional Income organisations : Collective Dairy / Marketing Livestock Sus. Agri plan, and annum Land implement development Land Access ¾ Village level

Skilling activists Wage and out Self emp. migration Employ ment ¾ Community best Development Indicators practitioners – Microfinance Better Human

Higher catalysts, trainers, Quality Secy Quality Education . Education Primary at +2 level mentors ECE Education Centre H&N Govt. 4 NDCC programmes Magnitude of the malnutrition Z40.4% of children withW under weight Z37.3% of children are stunted Z12.5% of children are wasted Z82.7% of children are anemic Z37.5% women with BMI<18.5Kg/m2 Z58.2% of women are anemic

Source: NFHS-3 Status of children among poorer sections in India

Stunted Wasted Underweight (height-for-age) (weight-for-height) (weight-for-age)

Scheduled Caste 53.9% 21.0% 47.9%

Scheduled Tribe 53.9% 27.6% 54.5%

Backward Class 48.8% 20.0% 43.2%

Other 40.7% 16.3% 33.7%

Source : NFHS-3 Figures are presented as percent of children who are below 2 standard deviations from the median growth indicator value calculated from the WHO reference population How far is A.P from MDGs (4 & 5)?

S.N Name of the IMR MMR CMR TFR o state 1 Andhra 49 W134 52 1.9 Pradesh 2 Karnataka 49 178 50 2.0 3 Kerala 12 81 14 1,7 4 Tamil Nadu 28 97 33 1.7

5 MDG target 28 109 42 2.1 set by 2015

Source : SRS 2007-09 Rationale W Z 56% of the SHG members spent their income on health related issues. Z Huge net work with Poor health and nutrition indicators Z No special nutritional care for vulnerable groups Z Lack of awareness about Govt schemes & low Utilisation Z Mismatch between the design and implementation of Govt schemes

8 Community managed health and nutrition interventions to reach MDGs

Universal Interventions (6336 VOs) (Common platform to converge for outreach sessions; BCC,W support for health emergencies, Anemia reduction)

Fixed NHDs Intensive Interventions (4200 VOs)

Regular capacity Nutrition building of cum Day Health spearhead team strategy Stake holders Care center Health (NDCC) 3. savings- 2. 5. 1. Trainings Convergen Health 4. HRF- Health at ce for Water and NDCC/S NDCC Sanjeevani agenda saving community Sanitation s-HRF HG Communit members health y Kitchen Gardens 9 Key elements of NDCC Daily use of Daily use of sprouts millets Balanced diet (3 meals)

NDCC

Growth Fixed monitoring NH Days NHED Complementary food

10 Common Interest Group Capacity building Community Garden (CIG) activities The design built in W 1. One-stop-shop : Access to nutrition & RCH services 2. Ownership : Community assisted and supervised feeding centers 3. Affordable : Member contribution Rs. 10/- per day towards quality diet cost which is less than the home diet 4. Sustainable: CIGs an opportunity for Pregnant & Lactating mothers to earn an income of > Rs 40- 50/day

11 Wight gain – Birth weight

Indicators NDCC Beneficiaries W (N = 234) Mean weight gain for pregnant women 9.01 (kg) (SD = 0.1557) Anemia detected during pregnancy (%) 35

Mean Birth Weight (kg) 2.912 (SD = 0.20) Weight Class (kg)

2.5 - 2.99 28.7 % ≥ 3.0 56.1 %

• 90% had normal deliveries • 10% had cesarean section. • 52% of pregnant women gained 9 -10Kgs weight Note: study conducted in 8 districts inclusive of mandals in 3 ITDAs. 12 Revenue generation activities (CIG)

The innovation: Cluster approach

• Primary CIG: Food basket • Collective procurement for cluster of 5-6 VOs • Profit: Rs. 5000 to 8000 per NDCC per month Branding exercise: NANYAM 13 Secondary CIG: Supplementary

activities “It was always my dream.. I had never imagined it would happen so soon. Now my centre • Nutritiousis fully sustainable..” snacks • Agarbatti- Satya, making CRP, Jogamperta • Paper covers • Adda leaves •Curd making •Garland making • Cloth business • Revenue: Rs. 2000- 3000 per month per NDCC

• Feasibility studies conducted by SPJMR & IRMA interns

Revenue from Primary & Secondary CIGs: Rs. 6000- Rs. 14 10,000 per NDCC per month Investment for one Village for 5 years: NDCC and AWC W Nutrition cum Day Care Centre (one Anganwadi time grant) Centre (Every year)

Unit cost (Rs) Unit cost (Rs) Consumption loan SNP cost for 80 corpus for 30 BPL APL+BPL beneficiaries 250,000 beneficiaries 360000

Health CRPs resource Salary component for fee & Health activist AWW and AWH 204800 incentives 30,000 Non –recurring House rent 12000 expenditure 20,000 Total 576000 Total 300,000 15 Note: Additional cost for monthly training at NDCC and induction/ refresher training at AWC Services provided at NDCC are complementary to AWC and not parallel structures.

S.NO Particulars NDCC AWC 1 Provision of diet NutritionallyW balanced diet Supplementary nutrition 2 Nutrient supply 2800 Kcals ; 500 Kcals ; 65 gms of protein 15 gms of protein Diet cost Rs 30/day/pregnant Rs 6/day/pregnant Rs 16/day/child Rs 4/day/child 3 Budget requirement One time grant Yearly release ( i.e.,Rs 3,00,000/center) ( i.e.,Rs 1,69,692/year) 4 Investment Capacity building Project mgt 5 Management Community owned Functionary driven 6 Nutrition Education 2 members at every SHG to Weakest component s of review, educate and encourage ICDS to practice at HHs 7 Capacity building Hands on training on regular No regular refresher basis ( Fortnightly) trainings for the functionaries 8 Community based Regular social audit to assess Weak accountability to monitoring the outcomes by external community. community representatives POP pregnant woman diet at Home, AWC and NDCC W S. No Food group At home AWC NDCC (RDA as per ICMR) 1 Rice & Millets 250 80g 400g 2 Dhal 10g 40g 55g 3 Leafy Vegetables - - 150g 4 Other vegetables 50g - 75g 5 Roots & Tubers - - 75g 6 Fruit - - 1 7Egg --1 8 Jaggary - - 20g 9 Oil 10g 10g 30 g 10 Milk - 250ml 11 Curd 50ml of butter - 50g 17 milk Repayment pattern W Z Diet cost : Rs 30-35/day W Member contribution : Rs 10/day W Income through CIGs : Rs 10/day W Interest thru’ internal lending : Rs 5/day W Dovetailing from ICDS : Rs 5/day W VO profits : Rs 5/day Total : Rs 35/day Z For children : Rs 12-15/day Time line for NDCC establishment W

1-4 • Implementation of Universal Interventions Months

5th • External Spear head team strategy Month • Internal spear head team strategy (1 Health Activist, 2 6-12th Health subcommittees, 1Cook) Month

13-24th • Sustainability of NDCCs Month

19 Investment -3 models W Budget heads Model 1 Model 2 Model 3 ( 20 ( 12 ( 5 beneficiaries) beneficiaries) beneficiaries) (In Rs) (In Rs) (In Rs) Seed capital 2,50,000 1,75,000 75,000 Equipment cost 20,000 20,000 20,000 CRPs support 30,000 30,000 30,000 Total 3,00,000 2,25,000 125,000

20 Financial sustainability

Member: Building Rs 10/- rent (Rs. Complete 400) CIG: Rs Complete 10/- repayment recovery of Fuel of diet cost expenditure (Rs. 800) ICDS: Rs @ Rs 35/- 5/- per Cook’s salary Internal member (Rs 500) lending: Rs NDCC 5/- Pregnant- 3 Diet Lactating- 4 V.O. Contri.: INCOME EXPENDITURE expenses Rs 5/- (Rs. 10,920) Children- 5 (10,436) (Rs 8736)

Internal Behaviour Spearhead SUSTAINABLE change in & CRPs NDCC community

21 Year wise establishment and Coverage of vulnerable groups W

4500 4000 2,20,800 4200 3500 3000 2500 2000 1500 No. of NDCCs 1000 1,05,600 1000 600 500 400 86,400 200 67,200 0 38, 400 2007 2008 2009 2010 2011

22 ICT Bringing technology to health Mobile Technology Health Passbook V O Input sheet

User friendly feedback monitoring and decision support system

23 M-NDCC W

24 DSS alerts W

25 NDCC sustainability W Convergence Reduction of Diet cost ICDS (SNP supply),NRHM Millets usage, PDS (NHDs, nutrition support), supply, community NREGS [ SSS(PLM) with garden (Land leasing – special works] & NPM practices) RWS for ODF villages

Revenue Generation Social capital Beneficiary Internal Spearhead Contribution, team availability to CIGs (Land based, provide counseling cluster approach, local at HH level resource based, nutritious snacks), Sustainability Internal lending, land of NDCC leasing Intra-sectors: Land, POP, Inter-sectors: Health, NPM, Marketing, IB, WD&CW, RWS and RD Disability and Gender 26 Convergence with ICDS, health and rural Development W • G.O. Ms No. 55 has been issued for universalization of ICDS with quality by integration of Anganwadi centres, NDCCs and ECEs in backward habitations, Tribal villages, fishermen habitations and SC ICDS Localities

• G.O.Ms. No. 4 has been issued for ensuring NDCC sustainability through revenue generation by Land- leasing and development of NREGS community kitchen gardens through tie-up with NREGS.

• Convergence with NRHM for Fixed NHDs resulting in 100% coverages for immunization, ANC ,PNC and Growth monitoring for NRHM children.

27 Comparison with NFHS 3 (17300 deliveries: 2007- 11) W 120 100 100 97.46 84 86.3 80 60.5 60 NDCC 42.8 42.9 38.9 40 Andhra Pradesh 40 31.1 30 India 20 5.4 0 Complete Complete Instl. Delivery Birth wt. < 2.5 ANC (%) immunization (%) Kg (%) (%)

28 Source: Internal MIS & Reaching the MDGs (17300 deliveries : 2007- 11) W 200 178 180 160 134 140 120 97 109 100 81 80 60 49 49 40 28 28 20 100.34 12 IMR 0 MMR

* MMR is measured against 1 lakh deliveries. As our 29 sample is 17,300, MMR shown is as an extrapolation. Source: Internal MIS & W External evaluation study results 2009 and 2011

30 Phase I: Platform establishment Utilization of public health facilities

68 % Deliveries at PHF 51 % Three ANC check-ups at 66 % 54 % PHF Regn. Of pregnancy at PHF

Percentage 92 % 84 %

HN + NDCC (N=234) Control (N=242) Study Group Utilization of ‘Provider-Dependent’ Services

90 83 85 80 78 78

56 53 HN + NDCC (N=234) Control (N=242) Percent

JSY Incentive Postnatal Complete ANC Full Check-up Immunization of Infants Study Group Wight gain – Birth weight

Indicators NDCC Beneficiaries W (N = 234) Mean weight gain for pregnant women 9.01 (kg) (SD = 0.1557) Anemia detected during pregnancy (%) 35

Mean Birth Weight (kg) 2.912 (SD = 0.20) Weight Class (kg)

2.5 - 2.99 28.7 % ≥ 3.0 56.1 %

• 90% had normal deliveries • 10% had cesarean section. • 52% of pregnant women gained 9 -10Kgs weight Note: study conducted in 8 districts inclusive of mandals in 3 ITDAs. 33 Phase II: Health Seeking Behavior Change Health Literacy Levels in Mothers

Knowledge of modes of transmission of HIV Beneficiaries in Heard of HIV/AIDS non-intervention villages N=242 Use of bed nets at home

Knowledge of bed nets to prevent malaria Beneficiaries in intervention Knowledge of modes of transmission of villages 237 malaria

Knowledge of malaria symptoms

Knowledge of methods to treat diarrhea

Knowledge of methods to prevent diarrhea

0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00% Mean Awareness Score (on Communicable Diseases) between Women in Two Groups (Maximum = 100)

65 61.54 % 60

55

50 48.82 %

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40 HN+ (N=234) Control (N=243) Maternal Health Behaviour Outcomes

Full Infant Immunization Breast Fed for 6 months No Pre-lacteal fluids rural India Colostrum fed (NFHS-3)

rural AP Cesarean delivery (NFHS-3) Delivered at home Delivered in private facility NDCC Delivered in Govt. Facility Beneficiaries

IFA Consumed for 90 Days IFA Received Three ANC visits

0 20406080100 Percentage Innovation for nutrition W

37 Cost Estimate Utilizatio n of •Outreach services public health •Referral Services facilities

178.18 Crore •Balanced diet •Complementary Nutrition food •Millets Rs. 8064 (micronutrients) ($168) per beneficiary Reduction of out of •HRF 2,20,800 pocket •CIG Benefici expenditur •CKG aries e

•Health Passbook ICT •Mobile technology •V O Input sheet Household investment v/s Project investment Child up Total Household Pregnanc Lactatio to 2 yrs of expenditure y n age incurred for quality nutrition Vulnerable stages care: Rs 15,860

NDCC •Investment per member: Rs 14,000 • Member contribution: Rs • Complete 5980 Maternal and child •Project contribution (one time grant): Rs 8064 care • Health Education • Health services Amortization of Investment over next 10 years 9000 8000 Number of 7000 beneficiaries 6000 (expressed as 5000 miltiple of 1000) 4000 3000 Investment per 2000 beneficiary 1000 Number of 0 beneficiaries (expressed as miltiple Investment per

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Year of 1000) beneficiary 2011 214.2 8309.991 2012 428.4 4154.995 2013 642.6 2769.997 2014 856.8 2077.498 2015 1071 1661.998 2016 1285.2 1384.998 2017 1499.4 1187.142 2018 1713.6 1038.749 40 2019 1927.8 923.3323 2020 2142 831 Policy influence

C M Announcements August 20th 2011, Jogampeta, Vishakapatnam

¾Rs 5 lakh grant to all NDCCs for building construction

¾Rs. 1 lakh as HRF to all SHGs with regular Health Savings

¾Expansion from 4200 to 36,000 villages across Andhra Pradesh.

41 The ecosystem established W Z Institutional architecture to have regular discussions on nutrition and health at SHGs Z Door step delivery of nutrition and health services Z Entrepreneur model of delivery Z Technical inputs through community nutritionist Z Best practitioners as counselors to influence household behaviors. Z Community gardens to influence dietary diversification at HH level too. Z Community based monitoring on nutritional outcomes Challenges W Z More investment of time in capacitating institutions- Discussions at SHGs and development of sustainable CIGs at NDCCs Z Long time to appreciate the power of the demand side approaches by the line depts for replication. Z Lack of baseline data for comparison.

43 Way forward W Z Reaching 15000 tribal, SC and ST habitations with intensive interventions by 2015 Z Reaching 38000 with universal interventions by 2015 Z External evaluation to measure the outcomes from time to time and make midcourse action Z Establishment of resource centers to train the social capital for replication

44 Conclusion W Z Model needs a network/platform for replication Z For scale up: Constant nurturing of the network members to plan, implement and monitor the interventions. Z The whole model can not be done in one go. It has phases W Establishment of platform ( 1st & 2nd yrs) W Focus to bring change in household behvaiours ( 3rd to 4th yrs) W Community based monitoring and audit (5th -6th yrs) Z Needs to establish partnership between the CBOs and line depts. Z Development of internal facilitators from the network for scale up and sustainability. Z External evaluations to make modifications/midcourse actions for replication/scale up.

45 Conclusion W Z Sustainable Z Community managed Z Scalable where SHG network/platform is available

46 For more details of the innovation W

1). http://go.worldbank.org/305MTTK2Q0

2). www.serp.ap.gov.in

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